If there is one primary motivator that initially brings patients to our offices, it is pain. For example, one typical case we see is the patient who presents with lower back pain and is given spinal manipulation with or without some kind of therapy and corrective exercise.Our pain relief success rate is legendary with this approach for many of these patients, but for many others, their problems can be stubbornly persistent and complex, with chronic recurrences that frustrate the best efforts of doctor and patient.
In the first article in this series ["Introduction to the Functional Movement Screen," Dec. 2, 2010 issue], I discussed the Functional Movement Screen (FMS), one of the critical components of the functional movement system developed by Gray Cook, MSPT, and Lee Burton, PhD. The FMS uses a standardized process involving seven basic tests to evaluate fundamental movement patterns, with a scoring system providing the means to not only assess injury risk and discover pain, but also to rate and rank movement patterns such as weaknesses, imbalances, asymmetries and limitations. The Selective Functional Movement Assessment (SFMA) takes evaluation of functional movement patterns one step further.
Evaluating Faulty Movement Patterns: The SFMA vs. the FMS
There are similarities and differences between the two screening procedures. Both the FMS and SFMA provide a complementary means to assess cause and effect, in addition to providing a rational for continuing care beyond the treatment of symptoms. The purpose of the FMS is predictive; assessing risk and discovering pain in movement patterns. The purpose of the SFMA is to assess the patient who is already in pain and to discover regional movement dysfunctions that cause local symptoms. The SFMA addresses the critical issue of regional interdependence.
Regional interdependence is seen throughout the interconnection of the myofascial, neural and even circulatory systems, as described by Thomas W. Meyers in his book Anatomy Trains. He states, "The muscle-bone concept presented in standard anatomical description gives a purely mechanical model of movement. It separates movement into discrete functions, failing to give a picture of the seamless integration seen in a living body. When one part moves, the whole body responds. Functionally, the only tissue that can mediate such responsiveness is the connective tissue."
Tom Hyde, DC, DACBSP, quoted in a Dynamic Chiropractic article describing spinal dysfunction, states: "Today there is more complexity with the description of subluxation. Now it can be defined as a more complex set of issues called spinal dysfunction." And Gray Cook lists subluxation as part of a joint mobility dysfunction classification that contributes to pain and dysfunction caused by faulty movement patterns in addition to soft-tissue and motor-control components.
Several questions need to be addressed when tracing all of our patient treatment needs. Are we too focused on chasing painful symptoms versus addressing a more complex regional issue that relates to the location of pain? If a corrective exercise is given, how do we know that it fits the specific needs of the patient? Why do highly trained athletes experience noncontact injuries, and why do patients seem to have chronic recurrences? Are we piling fitness onto dysfunction?
Planning effective care needs an accurate starting place. A functional diagnosis that demonstrates posture and movement patterns is crucial. The SFMA is an excellent tool for this task. With practice, evaluating a patient and discovering dysfunctions takes about 10 minutes.
There are seven movement assessments that comprise the SFMA. Caution! If these tests look simple or basic, you are right! However, how you interpret them is another story. Let's start with a brief description of the seven assessments.
The first assessment is the Cervical Spine Movement Assessment with three components: flexion chin to chest, extension face parallel to ceiling, chin left and right to shoulders. The second is the Upper Extremity Movement Pattern of the shoulder. Pattern one assesses internal rotation, extension and adduction of the shoulder; pattern two assesses external rotation, flexion and abduction of the shoulder. This also includes a pain provocation test; i.e., Yocum's impingement test.
The third assessment is the Multi-Segmental Flexion Assessment; starting with the patient standing erect and having them bend forward at the hips attempting to touch their fingertips to the tips of their toes. The fourth is the Multi-Segmental Extension Assessment, which tests for normal extension of the shoulders, hips and spine.
The fifth assessment is the Multi-Segmental Rotation Assessment; the objective here is to test normal rotational mobility in the neck, trunk, pelvis, hips, knees and feet. (All of these sound just like part of a standard chiropractic/orthopedic evaluation, don't they?) The sixth is the Single-Leg-Stance Assessment and evaluates independent stabilization of each leg with dynamic leg swings.
The seventh and last assessment is the Overhead Deep Squat Assessment for bilateral symmetrical mobility of the hips, knees and ankles. When the patient's arms are overhead, it also tests mobility of the shoulders and extension of the thoracic spine.
Assessment Categories and Clinical Meaning
Unlike the FMS, which uses a 0-3-point grading system, the SFMA places each movement assessment into one of four categories: Functional Non-Painful (FN), Functional Painful (FP), Dysfunctional Painful (DP) and Dysfunctional Non-Painful (DN). Since the SFMA is a tool for assessing patients with pain, which would be the most significant category for a given finding? This is where the significance and meaning of an apparently simple assessment tool is revealed. If you are thinking Dysfunctional Painful (DP) or Functional Painful (FP), it won't be the significant finding in regards to regional interdependence and discovering the source of pain and dysfunction. Of course, when painful findings are discovered, stop and treat the pain with the best means possible.
It is the Dysfunctional Non-Painful (DN) pattern that will most often lead us to the source of a regional problem causing local pain. This is our starting place that takes us through a flow chart to determine the appropriate corrective exercise and treatment strategies. For example, the nagging lumbar pain that persists, as mentioned at the start of this article, may have its genesis in an asymmetry in an extremity pattern, postural and alignment issues outside of the lumbar spine, or lumbar spine stability and motor-control issues, which may include inappropriate lumbar flexion instead of hip hinging.
The SFMA is for licensed health care providers only including chiropractors, physical therapists, medical physicians and athletic trainers. Combining the SFMA and FMS gives you a more comprehensive and effective tool for risk assessment, injury prevention and treating pain caused by movement dysfunctions. In addition, your patients will experience a reason to continue with care beyond pain relief, as it gives them a place to go; a road map to work from as they attempt to return to "normal." What could be better than providing lasting pain relief and corrective exercise care for a patient while progressing them to be more functional and stronger than when they entered our office?
- Cook G, Burton L, Fields K. The Functional Movement Screen Professional Training Manual.
- Kiesel K, Pliskey P. The Selective Functional Movement Assessment (SFMA) Training Manual: An Integrated Model to Address Regional Interdependence.
- Cook G, et al. MOVEMENT: Functional Movement Systems. Screening, Assessment, Corrective Strategies.
- Myers TW. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapies.
Installment three in this series will discuss the practical clinical applications of the FMS, SFMA and the "Turkish get up" as elements of a continuum of care for your patients.
Dr. Robert "Skip" George practices in La Jolla, Calif., where he integrates chiropractic, rehabilitation and sports performance training. He is a certified Functional Movement Screen instructor and has lectured nationally on subjects related to the chiropractic profession. He can be contacted with questions and comments at